Question

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following intervention should the nurse include in the plan

a.Document the client's behavior every 8 hr.The nurse should document the client's behavior every 15 to 30 min while the client is in seclusion.
b.Limit the client's fluid intake to 50 mL/hr.There is no indication to limit the client's fluid intake. The nurse should monitor the client every 15 to 30 min for hydration needs while the client is in seclusion.
c.Renew the prescription for the client every 4 hr.MY ANSWERThe nurse should assess the client's behavior frequently during seclusion and should renew the prescription for seclusion for an adult client every 4 hr, for a maximum of 24 hr.
d.Toilet the client every 4 hr.The nurse should offer toileting to the client every 15 to 30 min while the client is in seclusion.

Answer 1

A nurse's care plan for a client in seclusion should include frequent documentation of behavior, ensuring hydration needs, renewing seclusion prescription every 4 hours, and offering regular toileting opportunities. These interventions are essential for client safety, legal compliance, and human dignity.

Step-by-step explanation:

When a nurse is creating a care plan for a client in seclusion after the client has threatened harm to others, it is important to include interventions that ensure the safety and well-being of the client while also adhering to legal and ethical standards. The nurse should:

• Document the client's behavior every 15 to 30 minutes to ensure the client's safety and to maintain a record of their condition and behavior while in seclusion.
• Monitor the client's hydration needs every 15 to 30 minutes instead of limiting the client's fluid intake, ensuring the client remains well-hydrated.
• Renew the prescription for seclusion according to legal and facility guidelines, which often require reassessment and renewal every 4 hours for adults, up to a maximum of 24 hours without further psychiatric evaluation.
• Offer toileting opportunities to the client regularly, which should be about every 15 to 30 minutes, rather than every 4 hours, to maintain dignity and meet basic physiological needs.

Each of these interventions helps provide a balance of safety, legal adherence, and humane treatment for the client during a period of seclusion. Proper documentation and regular monitoring/reassessment are also critical for ensuring the justifiable use of seclusion and for the planning of subsequent care once the seclusion period ends.